<script src="<?php echo get_url('js/jquery.validate.js')?>" type="text/javascript"></script>
<script src="<?php echo get_theme_url('js/patient.js')?>" type="text/javascript"></script>
<div class="w1024 bc mt5 clearfix">
    <?php include get_tpl_path('center/patients_left_nav'); ?>
    <div class="doctor-container fr">
        <div class="user-tab f14"><span>基本信息</span></div>
        <div class="user-center">
            <p class="user-title">个人基本信息</p>
            <form class="p20 pr" name="update_userInfo_t" id="update_userInfo_t">
                <p class="mb10 clearfix">
                    <label class="fl">姓&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;名</label>
                    <input type="text" id="user_name" name="user_name" class="input-01" />
                    <span id="checkuser_name"></span>
                </p>
                <p class="mb10 clearfix">
                    <label class="fl">昵&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;称</label>
                    <input type="text" id="alias" name="alias" class="input-01" />
                    <span id="checkalias"></span>
                </p>
                <p class="mb10 clearfix">
                    <label class="fl">性&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;别</label>
                    <input type="checkbox" name="sex" value="1" class="ml10 mr5" />男
                    <input type="checkbox" name="sex" value="2" class="ml30 mr5" />女
                    <span id="checksex"></span>
                </p>
<!--                <p class="mb10 clearfix">-->
<!--                    <label class="fl">求医科室</label>-->
<!--                    <input type="text" class="input-01" />-->
<!--                </p>-->
                <p class="mb10 clearfix">
                    <label class="fl">与患者关系</label>
                    <input type="checkbox" name="relation" value="1" class="ml10 mr5" />本人
                    <input type="checkbox" name="relation" value="2" class="ml30 mr5" />家属
                    <input type="checkbox" name="relation" value="3" class="ml30 mr5" />朋友
                    <span id="checkrelation"></span>
                </p>
                <p class="mb10 clearfix">
                    <label class="fl">身&nbsp;&nbsp;份&nbsp;&nbsp;证</label>
                    <input type="text" id="sign_id" name="sign_id" class="input-01" />
                    <span id="checksign_id"></span>
                </p>
                <p class="mb10 clearfix">
                    <label class="fl">患病年月</label>
                    <input type="text" id="sick_time" name="sick_time" class="input-01" />
                    <span id="checksick_time"></span>
                </p>
                <p class="mb10 clearfix">
                    <label class="fl">出生日期</label>
                    <input type="text" id="birthday" name="birthday" class="input-01" />
                    <span id="checkbirthday"></span>
                </p>
                <p class="mb10 clearfix">
                    <label class="fl">所在城市</label>
                    <select name="province" id="province">

                    </select>
                </p>
                <p class="mb10 clearfix">
                    <label class="fl">联系地址</label>
                    <input type="text" id="address" name="address" class="input-01" />
                    <span id="checkaddress"></span>
                </p>
                <p class="mb10 clearfix">
                    <label class="fl">手&nbsp;&nbsp;机&nbsp;&nbsp;号</label>
                    <input type="text" id="phone" name="phone" class="input-01" />
                    <span id="checkphone"></span>
                </p>
                <p class="mb10 clearfix">
                    <label class="fl">固定电话</label>
                    <input type="text" id="home_phone" name="home_phone" class="input-01" />
                    <span id="checkhome_phone"></span>
                </p>
                <p class="mb10 clearfix">
                    <label class="fl">邮&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;编</label>
                    <input type="text" id="zipcode" name="zipcode" class="input-01" />
                    <span id="checkzipcode"></span>
                </p>
                <p class="mb10 clearfix">
                    <label class="fl">邮&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;箱</label>
                    <input type="text" id="email" name="email"  class="input-01" />
                    <span id="checkemail"></span>
                </p>
                <div class="fl mt20 ml15 mr30 pa t0 r5">
                    <img src="<?php echo get_theme_url('images/index-logo.png')?>" alt="头像图片" width="100" height="100" />
                    <span class="f12 mt30 ml10 in_b">注：图片最大为xxM，将显示在网站上<br />建议上传个人头像</span>
                    <div class="mt10">
                        <a href="javascript:;" class="button-01">上传头像</a>
                    </div>
                </div>
                <div class="mt20 tc">
                    <input value="提交" type="submit" class="button-01 mr20">
                    <input value="取消" type="reset" class="button-01 mr20">
                </div>
            </form>
        </div>
    </div>
</div>